DIAG 2740 Chapter 9 Case Studies

DIAG 2740 Chapter 9 Case Studies - Chapter 9 Cases Case#1...

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Chapter 9 Cases Case #1 Complete Paralysis and Loss of Sensation in One Arm Chief Complaint A 60 year-old man with a history of lung cancer gradually developed severe pain, weakness, and numbness in his right arm. History The patient smoked for 34 years. Two years ago he was diagnosed with lung cancer and underwent a right upper lobe lung resection followed by radiation and chemotherapy. Six months ago he developed shooting pain and swelling of the right arm. He gradually lost all strength and sensation in the entire right arm up to the shoulder but continued to have severe burning pain. Past medical history was notable for right eye surgery followed by an assault with a baseball bat 20 years ago. Physical examination Vital signs: Temperature = 99.4º Pulse = 110 BP = 130/80 Neck: supple, no tenderness Lungs: clear Heart: regular rate with no murmurs, gallops, or rubs Abdomen: normal bowel sounds, soft, no masses Extremities: right arm swollen, with two firm 5 cm discolored masses- one in the right axilla and one on the upper right chest wall. Also marked clubbing of the fingers bilaterally. Neurologic exam: Mental status : alert and oriented x3 Cranial nerves : intact, except for the right eye, which had an irregular pupil and diminished vision in both the lateral and medial fields. Motor : normal tone, except for the right arm which was flaccid. Strength was 5/5 throughout except for 0/5 strength in the right shoulder, arm, and hand. Reflexes : 2+ throughout, except for absence of right upper extremity reflexes Coordination : normal finger nose testing left arm, unable to test right arm. Normal heel shin testing Gait : normal Sensory : absent light touch, pin prick, and vibration sense in the entire right arm up to the deltoid. Sensation is otherwise normal.
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Localization and differential diagnosis 1. On the basis of the signs and symptoms shown in bold above, where is the lesion? 2. This patient had an abnormal right eye due to trauma. If the right eye had been normal previously, what additional finding might have been present on the exam that would help in the localization? 3. What is the most likely diagnosis? Case #2 A Newborn With Weakness in One Arm Minicase A 3 week old infant girl was brought to the pediatrician because of left arm weakness. She was born at 42 weeks (2 weeks past due) weighing 10 lbs. 11 ounces, and the delivery was complicated by shoulder dystocia (difficulty delivering the shoulder) resulting in significant traction of the left neck and shoulder during delivery. Left arm weakness was noted at birth that improved slightly but was still present at the appointment. Exam was normal except for the upper left extremity, which had decreased tone and lay internally rotated at the infant’s side with decreased spontaneous movements. She did not abduct the left arm or flex it at the elbow, but did have spontaneous opening and closing of the hand with normal grip strength, normal elbow extension, and some wrist flexion. The left biceps reflex was absent
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DIAG 2740 Chapter 9 Case Studies - Chapter 9 Cases Case#1...

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